Challenges and innovations in access to community‐based rural primary care services during the Covid‐19 pandemic in Australia

Abstract Background Access to primary care is a significant issue for rural populations. The Covid‐19 pandemic imposed a unique operating environment for rural General Practice enabling accessible services. This study aimed to explore the challenges and innovations rural General Practices experienced in promoting accessible primary care during a year of the pandemic. Methods Longitudinal semi‐structured interviews were done with key informants (General Practitioners or Practice Managers) from purposefully selected General Practices from different rural towns in different subregions. Interviews occurred at three stages of the pandemic, June 2020–June 2021. They explored participant perspectives of the emerging challenges and innovatinos as they sought to support accessible primary care services during the pandemic. The data were thematically coded using a deductive framework of access challenges and innovations over time. Results Of 12 practices approached, 11 key informants responded, providing around 30 h of interview data. The challenges and innovations related to access, changed over time as the pandemic evolved. A common theme concerned reflexive action. Practices had been on a journey during the pandemic to embed new planning processes, digital health options and to innovate to protect and support patients and staff to sustain access. Conclusion This study provides useful insights into the challenges and innovations experienced in rural general practice during the Covid‐19 pandemic to reflect on models, strategies and approaches that can apply to promote access to rural primary care services going forward.


| INTRODUCTION
Rural General Practices (practices), which consist of doctors and practice staff, play a critical role in delivering primary care services, protecting the most vulnerable people by providing local care to rural communities, overcoming the barriers of distance and cost. 1 During the Covid-19 pandemic, Australian General Practices, which work as independent business (Box 1) were faced with enormous pressure to evolve their services to ensure access to primary care, within a new operating environment. Specific to practices based in rural and regional settings, the pandemic issues came atop of existing pressures of operating with more limited workforce and promoting accessible services for clients with complex needs, who are spread over long distances. 2,3 Primary Health Networks (PHNs) were an important part of Australia's support system for General Practices at this time (Box 1). There are 31 PHNs across Australia who are independent agencies who work with General Practice and other stakeholders to strengthen and coordinate primary care services to deliver high quality primary care services which meet the needs of communities. 4 This study was led by Murray PHN which has responsibility for a wide rural and regional catchment of 22 local government areas and around 200 General Practices spanning the north west to north eastern corners of Victoria (Box 1). It is located in the state hardest hit with the pandemic, Victoria (Box 1). The pandemic situation presented an opportunity for Murray PHN to explore the service challenges and innovations for practices related to maintaining access for rural communities. Aggregating the learning from doctors and Practice Managers who work in different types of practices in different subregions and exploring their perspectives over time was expected to inform the Murray PHN and its advocacy for wider system responses so as to meet the needs of rural General Practices and support accessible services for the community. options and to innovate to protect and support patients and staff to sustain access.

Conclusion: This study provides useful insights into the challenges and innovations experienced in rural general
practice during the Covid-19 pandemic to reflect on models, strategies and approaches that can apply to promote access to rural primary care services going forward.

K E Y W O R D S
access, Covid-19, doctor, General Practice, primary care, rural, telehealth

Box 1: Summary of Australian primary care system and role of PHNs
In Australia, the primary care sector operates mainly as a set of independent businesses which have the opportunity to set their own fees.
Patients have the opportunity to receive services at no cost if doctors choose to keep their fees at the level that a national universal health insurance scheme pays for services on a Medicare Services Schedule. 5 Overall, 31 PHNs across Australia play a role in promoting General Practice services that are high quality and accessible to patients, particularly for at risk groups. 4 The Murray PHN is based in regional Victoria, in the state which had the most significant rates of Covid-19 infection and death Australia-wide and. 6 During the pandemic it continued to work with its 200 General Practices and other stakeholders to promote high quality, accessible primary care services for rural and regional communities by responding with information and resources.
Meanwhile, its catchment was subject to protracted lockdowns and border controls, new infection control protocols and immunisation requirements.
The regulations imposed on Murray PHNs' General Practices were controlled by the states under Australia's public health law, whereas the Commonwealth (federal government) were responsible for pandemic resources for General Practices including providing protective equipment and expanding Medicare to allow for telehealth billing. 7,8 The states co-managed immunisations with the Commonwealth.
The Murray PHN had a strong interest in responding to access challenges and sponsored this study to learn more about the rural and regional practice experience and innovations that are possible to scale up.
The Commonwealth (federal) government is the main funder of PHNs and recognises that a coordinated response by General Practices as critical to the overall Covid-19 response. 5,9 In rural settings General Practice is the main medical service that is available to people. 10 Meanwhile, under law, the Victorian government sets public health regulations, such as state-mandated lockdowns and co-funds immunisation with the Commonwealth. Despite extensive policymaking and resourcing by state and federal government in response to different stages of the pandemic in Australia, there was limited information about the challenges and innovations in rural and regional General Practices and how they innovated to meet the primary care needs of local communities. Such information has the potential to inform how to strengthen rural and regional primary care which is a critical issue given that around half of the world's population 11 and 30% of Australia's population that lives rurally. 12 Several national-scale Covid-19 specific cross-sectional surveys were done in Australia in 2020, describing patterns of response in General Practices. These suggested that practices rapidly pivoted from a normal business model in the early pandemic, including introducing a range of innovations in infection control, telehealth and additional prevention services to meet the needs of practice staff and patients. 6 The results also suggested that rural communities encountered different challenges than those in metropolitan areas, such as issues with managing patient transfers. 6 Metropolitan practices by comparison, were more likely roster more staff in response to the pandemic pressures, do less ambulatory services and ask colleagues for resources. 6 With regard to sourcing more staff during the pandemic, other research suggests that rural practices have ongoing workforce recruitment and retention challenges which increase by rurality. 13,14 Rostering more staff may not have been a viable option in rural areas, including when international border closures which Australia imposed in 2020 may have affected the capacity to access overseas-trained doctors on which many rural areas rely. 15 Under normal conditions, rural doctors are also known to work in more isolated and busy conditions (longer hours), particularly when managing both practice and on-call and hospital specialist rosters in an environment where there are limited other doctors. [16][17][18] Perhaps highlighting the busy-ness of General Practice in the rural and regional context, a further national cross-sectional survey during the pandemic identified that these practices may have been less likely than those in metropolitan areas to experience a fall in patient numbers and a loss of income during the pandemic. 19 An international perspective equally noted that rural and regional General Practices may have nuanced pandemic risks, resilience and need context-based responses that need to be accommodated as part of pandemic planning. 10 These include managing pandemics atop of regular care for a population with poorer health and socio-economic status, longer distances, different population interaction patterns, reliance on mobile workforces 15 and limited local technical infrastructure. 10 As such the integration of any pandemic-related health service requirements into rural systems is likely to have required specific framing, expertise and adjustments to meet the needs of the practice and the community. 20 This fits with other research, showing that outside of pandemic situations, rural primary care needs to respond to constant adaptive pressures to address risk and capitalise on opportunities which help them to remain viable in the face of a changing health system environment. 21 Understanding the level of challenges and innovations in rural and regional General Practices during the course of the Covid-19 pandemic, could provide rich information for rural-sensitive national and state pandemic policy and planning.
Finally, there have been a range of published narratives which are enthusiastic about learning from the pandemic to re-set a 'new normal' 22,23 but it is important to understand the layers and context of the 'new normal' with regard to rural General Practices using empirical data, before any widespread change, is espoused. To understand this better it is relevant to use longitudinal research methods which are powerful for exploring reactive and adoptive processes within complex and dynamic health systems. 24 With this background in mind, this study aimed to explore the challenges and innovations of rural General Practices in promoting accessible primary care during 1 year of the pandemic in a state that was hardest hit with Covid-19.

| Context
The study was funded by the Murray PHN (Box 1). 4

| Procedure and semi-structured interviews
The study had ethics approval from Monash University, Project ID: 24918. It involved semi-structured interviews over an annual period 2020-2021, including three different stages of the pandemic's evolution (Table 1) The interview guide was developed by the researcher collaborating with the Murray PHN staff so as to optimally inform Murray PHN policies as well as the broader literature. The guide was revisited between each round of interviews to update the questions so as to expand on the findings of previous rounds of interviews and to understand emerging phenomenon as the pandemic situation changed (Table 2). Participants were asked to describe their practice's current services and community, models of care they used, workforce, challenges and innovations related to addressing the needs of various sub-populations and sustaining care under evolving pandemic conditions.

| Analyses
The analyses were informed by cross-situational learning where learning about phenomenon occurs through multiple exposures where there may be exposure-by-exposure uncertainty and a lack of referential material (new pandemic conditions that are constantly changing) but meaning is sourced from combining multiple reference points. 26 This theory, although currently rooted in word leaning, allows for describing learning in complex dynamic systems where practices were responding to unpredictable pandemic policies and community needs over time. Other specific health services theory which informed the analysis was diffusion of innovation where linkages between resource and knowledge systems related to the piloting of innovations relative to system readiness, practical experience of those innovations and the consequences of not acting. 27 Further, the researcher interpreted the emergent findings using thematic analysis based on a deductive coding framework concerning access, challenges and innovations by time period. These

Stage of the pandemic Conditions
Stage 1-June 2020 State-wide lockdown (stay at home orders), work from home orders, with protocols around managing Covid-19 clinical risk including use of screening and personal protective equipment and using telehealth GPs pivoted to telehealth models mainly due to infection risk (initially with no funding for this).
New government-funded telehealth item number eventually introduced for GPs; practices and required practices to bulk bill (not change out of pocket costs) for it (fee set) 25 Stage 2-December 2020 State-wide lockdown (stay at home orders) eased, but workplaces and venues still running at capacity limits to prevent spread of Covid-19 Population had moved to regions as many able to work from home, resulting in rural population growth Telehealth item expanded (more eligibility, phone and video) and practices permitted to charge patients out of pocket fees for it 25

Stage 3-June 2021
Vaccination roll-out commenced, and practices enroled to supply vaccinations through an expression of interest process to the Government (gained accreditation to deliver) Vaccination supply limited to 50 vaccines per practice per week initially due to national supply chain limitations, then expanded based on practice utilisation data Guidelines for safety of various vaccines evolving within national policy (perceived risks creating vaccine hesitancy by community) Vaccination programme implemented in staggered way based on infection risk in pre-set phase Telehealth item available ongoing, but limited to phone (not including video) T A B L E 1 Pandemic timeline underpinning this study were defined based on internationally acceptable frameworks 28,29 where these were available and further informed from the perspective of the research team and Medical Advisors within the PHN, to ensure they aligned with the context under study ( Table 3). The framework used to define access is known to constitute supply (practice and service factors) and demand side (Patient) considerations. 28

Stage 1 (June 2021) Stage 2 (December 2021) Stage 3 (June 2022)
Firstly, can you tell me a bit about your practice and community?
Thanks for talking with me again Thanks for talking with me again Can you tell me a bit about your experiences working in primary care during the Covid-19 pandemic? What have been some of the barriers and enablers?
How have things been progressing since we last spoke? Just to recall, we were in the state-wide lockdown at that time. What is it like now? What are some of the current barriers and enablers?
How have things been progressing since we last spoke? Just to recall, the state-wide lockdown had eased but we were still waiting on vaccinations. What is it like now? What are some of the current barriers and enablers?
Are you using any new models (in-practice, on-call roster, aged care and/or other specialist clinics)?
Have you noticed any changes to your practice, new models, networks?
Have you noticed any changes to your practice, new models, networks?
Have you changed anything about the way you are working with others in the community?
How are they working at the moment in terms of meeting the needs of the practice and the patients?
How are they working at the moment in terms of meeting the needs of the practice and the patients?
Were there any enablers or barriers to these models/networks or approaches in terms of meeting the needs of the practice and the patients?
How are you managing vulnerable patient groups? Is there anyone you sense who needs more care or who is missing out?
Are there currently any groups who you think is presenting more or who might be missing out on care at the moment? What are the barriers and enablers to their care?
Are there currently any groups who you think is presenting more or who might be missing out on care at the moment? What are the barriers and enablers to their care? To support a deeper understanding of the data, interviews were transcribed verbatim, read through repeatedly by the researcher and coded deductively. 30 Interviews were analysed by stage first, and then as a longitudinal dataset to ensure that different challenges and innovations of the pandemic were reflected upon at each stage, and then consid- Emerging themes were discussed with Murray PHN staff in bi-monthly meetings which were recorded in working notes and used to clarify, annotate, and organise material in a way that made sense, layering and reorganising themes, and drawing on the deep knowledge of Murray PHN staff. 31 The Murray PHN staff regularly challenged the researcher's ideas, which helped to reduce subjective biases and test any assumptions. 32 This aided validation. By discussing the themes regularly, issues were raised that led to deeper analysis, allowing for internal confirmation or disconfirmation. This process enabled thick description and triangulation until a final set of themes was agreed upon.
To aid interpretation of the data, a subtext of E, M or L was applied to define early (including registrar), mid or late career participants or P, Practice Managers. In the sub-text, the practice staffing was reflected in full time equivalent

| RESULTS
Of 12 practices contacted, 11 key informants from different practice and subregions enroled in the study and participated in at least two rounds of interviews (eight participants completed all three interview rounds [around 30 h of interview data]). Three participants were from solo community practices. Participants included a mix of female and male, mid-, and late career GPs/Practice Managers and those in varying practice employment and practice sizes, including servicing aged care, hospitals, and multiple practices and working in different levels of remoteness ( Table 4).
The results are summarised in Table 5 and described below.

| Stage 1-Challenges
In the first stage, when lockdowns were imposed and practices had to pivot to the use of telehealth (

| Stage 1-Innovations
In the first stage, most of the innovations in practices related to infectious diseases prevention and control measures which were retrofitted each practice's infrastructure, skills, and interests. Some novel models emerged including driveway consults and carpark examinations, '… we negotiated access to a driveway of a neighbouring property from Service an on-call roster, aged care and/or other specialist clinics in the town

| Stage 2-Challenges
In the second stage, borders had re-opened and the state-wide lock-down had eased (

| Stage 2-Innovations
At the second stage, the innovations were driven by the expansion of telehealth reimbursements from the Australian government and the flexibility for practices to bill for it as they chose. Practices contemplated how to use the right mix of care modalities to support access. Many contemplated this innovation around patient limitations, patient characteristics, their healthcare needs and the doctor's satisfaction with the quality of care that could be provided,

| Stage 3-Challenges
In the third stage, the national vaccination programme had started rolling out (

| Stage 3-Innovations
In the third stage, with more security around ongoing telehealth funding for telephone only, the innovations involved practices embedding telephone use into the practice model of mostly face-to-face services.

| DISCUSSION
This longitudinal qualitative research provides some useful insights into the evolving challenges and innovations related to promoting access by rural General Practice during an intense year of policy change during the Covid-19 pandemic. There are signs of major practice challenges and adaptations over time in relation to access, including managing major stressors such as maintaining community confidence and connection to local services, supporting the evolving needs of different patient cohorts and responding to local resource challenges (time spent planning, organising staffing and infrastructure and ensuring safety under pandemic conditions). In terms of theory about the diffusion of innovation, whilst the rural and regional General Practices showed that they have the capacity to mount a substantial response within pandemics, the number and size of changes at the macro level of the health system, such as new pandemic policies, can quickly overwhelm their systems. 27 Further, their capacity to pursue innovations whilst managing challenges to service access, relies on state and national resource systems which may lag in their delivery.
Therefore, rural and regional practices may have additional pressures to mount workarounds. Further, if pandemics emerge rapidly, practices are required to respond within the limits of their local resources, with some starting new models like driveway consultations, but these may not be universally possible depending on the community. Overall, with regard to rural and regional practice, they may have more challenges mobilising pandemic resources because they start pandemics with a greater relative service demand 3 and the need to adjust pandemic responses to cope with a higher risk clientele who needs to travel further to get health services. 10 In the Australian context, the PHNs and other stakeholders are likely to play a part in forecasting, advocating, and coordinating resource needs during pandemics, particularly for the rural and regional primary care sector. As a broker between the individual practices and the levels of government, PHNs have the potential to promote more of the intended outcomes of government pandemic policy and reduce more of the unintended consequences, also aggregating the government communications about the rapidly emerging pandemic policy settings to ensure that they make sense in the local context relative to resources.
Meanwhile, aligned with diffusion of innovation theory, the practices showed a strong imperative to evolve their service models to minimise consequences for the community and maximise business viability. 27 This was most demonstrated through the application of telehealth over time, where it was tested and refined until it became more embedded in the practice with a clear purpose and to drive business revenue. Due to the wide variability in General Practices and communities and variation in issues like distance and costs, the rate and level of innovations at any one practice naturally varied greatly over the course of the study period. However, there was a universality in the voice of respondents, about their commitment to respond to local access needs likely due to the consequences of not doing so (Covid-19 related morbidity and mortality). Consequences are a key driver of adopting innovation. 27 With regard to telehealth, the macro systems change like the government's new opportunities for bill for telehealth appointments (initially requiring telehealth only models due to infection risks), met with significant effort by practices to trial and reflect on the use of telehealth in different forms in their local context, and then embed mostly telephone consultations for specific situations. The situations where it was deemed useful were mostly as telephone appointments within a hybrid service model, to manage waiting lists and promote convenience for rural patients, and to extend the business hours. This response to telehealth is strongly reflected through cross-situational learning theory where emerging conditions were unknown and flexible response was needed to maintain services and adjust to emerging needs. 26 The rapid policy changes and the size of the responsibility on small staffing within rural practices showed signs of producing a major workforce burden over the study period. This is a major concern in an environment where recruitment and retention challenges are already common. 34 Rural workforce capacity should be a major consideration in ongoing pandemic planning for its major potential to impact accessible rural primary care. The findings suggest that policies around standing staff down who have been potentially exposed can have a major impact on rural access. Further, the major administrative and clinical planning capacity required for rural practices to respond to pandemic-related care for a wide geographical population with high care needs, could be a major barrier to rural primary care sustainability. This reinforces the findings of a perspective about rural pandemic preparedness. 10 The study also identified major changes in the needs of rural patients which could impact access to rural primary care. Over the study period, there were signs that rural population size and mobility patterns had the potential to change in line with other perspectives. 10 Further, practices identified that there was an increasing demand for care to support community anxiety, manage more complex and mental health conditions, as well as demand by older frail patients due to physical and cognitive decline during periods of isolation. The study respondents noted the need to ensure access for patients with longstanding issues which were exacerbated by deferred reviews as well as handling additional caseload related to causes in the pandemic environment. Longer appointments were needed but once again there were not necessarily more doctors, and doctors tended to a higher proportion of more serious patients which could be a burden for sustaining their own well-being (minimal simple caseload).
This study has limitations. It is exploratory only, based on a small sample of practices, including a mix of GPs and practice managers in different rural towns. Although the study explored a range of issues over time, due to the breadth of issues and variability of context, caution should be used when generalising these findings to other settings. Given the research showed that innovations emerged over time, it is recommended that follow-up research is pursued.

| CONCLUSION
This longitudinal qualitative research provides some useful insights into the evolving challenges and innovations related to promoting access by rural and regional General Practices during an intense year of policy change during the Covid-19 pandemic. A common theme concerned reflexive action, to the extent to which practices had been on the journey to embed pandemic planning processes, digital health options and innovate to protect and support patients and themselves to sustain access. The research reinforces the need for resource coordination, support for communications, and forecasting and managing rural and regional primary care needs with levels of government, to achieve intended outcomes related to service access.